Workers' Rights & Cuba's Medical Missions

It is four in the morning, still dark out and very humid. Ofelia gets up, showers outside behind her house, and gets dressed. The uniform is always the same, a knee length, pleated skirt with a button down white blouse, and a short white coat. Some mornings she has a cup of water with sugar, most mornings she doesn't have anything at all. Ofelia heads out, walking about 2 kilometers where a construction truck picks her up along with several of her neighbors. She rides in the trailer of the truck, standing and holding on. The truck drives about 20 kilometers, dropping her off at the entrance to the town. Here, she walks 6 kilometers more towards the center of town, in total about 5 miles which takes on foot over an hour. Ofelia is a medical student in Cuba, and she is part of Cuba’s most profitable export. 

Every year, the Cuban government makes around 11 billion dollars through its medical missions, more than its tourism industry, and more than exports like tobacco and sugar. In early 2020, the world watched in horror as the COVID-19 pandemic ravaged the country of Italy. Cuban doctors made headlines arriving at the height of the crisis to provide aid, carrying the Cuban flag as they came off the plane, a moving image that is haunting given the murky industry that is Cuba’s medical missions.

“[00:10:25] Now, that's basically what by that I mean why they tell everybody thinks Cuba is like a super power when it comes to matters and it's also not free. Well, they tell you the education ministry is not free because once you become a doctor, you if you leave the island, you can not come back to the island in eight years. But once you become a doctor, they can send you anywhere in the island to that remote worst places in the island. If they want to send you that, they have to have to go there because you belong to them. That’s what they tell you, that you’re a medio basico de la Revolucion.”

Cuba’s medical missions began after the 1959 Revolution, when Fidel Castro overthrew the right-wing government run by Batista and instituted a Communist regime. Healthcare and education were integral to the Castro regime. Even after Cuba lost the support of the Soviet Union, it continued its medical missions. How does the Cuban government continue to send out so many physicians each year? How does it tout one of the highest physician ratios in the world, even when many of its hospitals are in disrepair and experiencing medication shortages? What are the conditions like for doctors working international missions? It is a source of pride and altruism today, as Castro called it “the army of white robes”? Or is it something much more sinister, as the U.S. State Department has stated “a form of human trafficking and modern slavery?” (Wulfhorst). 

Cuba has one of the highest physician to population ratios in the world. Compared to the US, it has about three times more doctors per capita. Unlike the US, where medical school admissions are competitive and limited, Cuba provides scholarships, known as becas, to students hoping to study medicine. Young, academically driven students looking to have a career often feel like medicine is their only option on the island. 

“[00:00:40] Por ejemplo, eso de la potencia médica de Cuba de verdad, una potencia médica, si Cuba es una potencia médica, porque en Cuba lo los estudiantes había más facilidades, el médico seguro por decir soy un profesional, verdad? Porque en Cuba no hay vida para un periodista o una carrera de abogado, eh?”

She says, they don’t feel like there is a career as a lawyer or journalist, so they end up in medicine. That’s Vivian Alvarez, a former employee of the Health Department in Cuba where she worked regularly with doctors, coordinating care and medical missions. 

“[00:02:10] I mean, fifteen thousand medical students every year. They become doctors in Cuba.”

And that’s Vivian’s partner, Orlando. Orlando left Cuba, but still stays in regular contact with his family and friends there, including his older brother. He helps out financially as much as he can. 

Although medicine guarantees a career, in Cuba, it does not guarantee a better life. Cuban doctors spend months to years on medical missions abroad, away from family and friends. Many do not get a say in where they will be posted. They can make up to 1000 US dollars a month working abroad, but more often make much less than that, around 100 to 300 dollars depending on how long they’ve been away. This is a huge incentive, given that many stores on the island only accept US dollars for goods.

The working conditions abroad are poor. Viviane commented on the strict rules doctors are under outside of the island: 

“[00:19:15] Ellos no tienen una vida social. Ellos no pueden tener nada solo por eso mismo, porque ellos no quieren que puedan procrear algo debido a tanto tiempo que se pasan trancados un años.”

Doctors are not allowed to have any sort of social life while on missions. They are also not allowed to have sexual or romantic relationships with any doctors on the mission with them, or anyone in the community. The government wants to make sure doctors don’t have an out. If you have a kid in another country, you have a reason not to come back to Cuba. They don’t want the children of these doctors getting citizenship in a country like Brazil for example. 

“[00:15:38] Porque no, porque a ellos les importe lo que tú haces con tu vida privada, sino porque ellos están evitando el tu tener un bebé y que nazca en ese país y entonces ya tú te quieres quedar verdad? O que te van a sonalidad. Ayuda todos los beneficios que tú no tienes en Cuba, que tú no lo ves.”

It is also a form of control. The living situation is typically outside city limits. By keeping doctors isolated from the community, the government prevents escape of any sort. Doctors cannot demand better conditions when they have no access to life in the community they work. Viviane noted that many doctors don’t know there is another way of life outside Cuba, and when some have found ways to escape, they have discovered these different ways of living. But escape comes with huge fear of the repercussions if they are caught, including getting sent back to Cuba and losing their salary. 

On each mission, military personnel sometimes undercover accompany the doctors to enforce the government’s strict conditions. Some doctors have even had their passports taken from them upon arrival by military personnel. 

“[00:18:08] And that group, at least two or three people works , straight to the to the government and information, and they tell you you cannot leave if you leave we are gonna look for you, we're going to. Take away your family in Cuba, but normally it's like something like the CIA like the military and intelligence in each group.”

With poor working and living conditions, and social contact completely off-limits, doctors also experience discrimination from the very communities they are there to serve. Local doctors often view Cuban ones with disdain. Cuban doctors are like a bandaid on the huge wound that exists within these countries. The wound? The various inequities within their own healthcare systems that go unaddressed by their own governments. Governments supplement with Cuban doctors, having no real drive or incentive to address the shortcomings of healthcare and access. 

Because Cuba is able to produce so many doctors, the ones with the most experience are often sent out on the missions.

“[00:04:18] Yeah. Basically the doctors with good experience are the hospitals are the ones that they sending out and what they have on the island right now is it's, you know, like young people, they don't have the sufficient experience.”

The government invests their physicians and exports medications in medical missions because of the large profits it rakes in for the government. This comes at a huge detriment to the health of the Cuban public. Medication shortages are common. So are unsanitary conditions. In rural parts of the island, like where Orlando’s family resides, outbreaks occur with no physicians or treatments to address it. 

Because many of the physicians still on the island are fresh out of medical school, they often lack the skill or experience to treat the public. Vivianne and Orlando both spoke at length about their own personal experiences navigating care for ailing family members. It is hard and painful to know that preventable and treatable diseases end up escalating and taking away loved ones. Both Vivianne and Orlando have lost several family members this way. 

Orlando talked at length about conditions in the hospital:

“[00:27:25] Oh, yeah. I mean, the hospitals. I mean, they have no sanitation at all. They sometimes they don't. They don't even have running water. And they have the same bathroom for everybody, and they don't have that they don't have hot water, no hot water, there is no hot water in the hospitals. Thank you. If you want to take a shower, like I say, it's sometimes it's not even water in there. You have to bring your own blankets. If you're going to get surgery.You have to bring your your your blanket and your colors and anything that you need, your own soap. Because they don't have it, yeah, now most of the hospital, the room, they don't even have the AC working.”

Some Cubans are able to access medications or better care by bartering with pharmacists or befriending government officials that can get them into the better tourist hospitals. This isn’t a common experience however. 

“[00:29:02] I mean, if if you are to get in, you know, if you follow all the news that they give to the people, I mean, it's completely different. If you go to Havana to go to hospital that you mentioned, the Cimeq is completely under military control. But if you go there and you pay with dollars, I mean, do you get a different, completely different attention for the Cubans? If you don't have a good relation, somebody with power, you will. They will. You won't be able to get into the hospital.”

It is a harsh and stark reality, a country that provides so much aid, yet seemingly fails communities on the island. And even harsher, the reality that this aid exists on the backs of many Cubans wanting a better life for themselves and their families. 

On November 29, 2018, Cuban doctors working on missions in Brazil filed claims against the Pan American Health Organization, an international public agency underneath the World Health Organization. The claims stated the agency has made $73 million dollars off the missions and also supported working conditions that violate forced labor laws. 

Despite the claims, nothing has changed and the missions won’t slow down anytime soon. They will continue raking in billions of dollars annually for the Cuban government.